Provider Demographics
NPI:1093384240
Name:POTTLE, DAKOTA
Entity Type:Individual
Prefix:
First Name:DAKOTA
Middle Name:
Last Name:POTTLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 NETWORK CENTRE DR STE 2
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-4637
Mailing Address - Country:US
Mailing Address - Phone:217-540-5100
Mailing Address - Fax:
Practice Address - Street 1:1200 NETWORK CENTRE DR STE 2
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-4637
Practice Address - Country:US
Practice Address - Phone:217-540-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN26069122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist